Sandhya Gardner, MD, Chief Medical Officer, Relias, December 4, 2017
There has been no shortage of attention given to the current opioid abuse and overdose epidemic sweeping the U.S. Near-daily media reports highlight the staggering number of people who are addicted to prescription and illicit opioids and who die from them daily. Nor have suggested remedies been neglected. Federal regulatory agencies, including the FDA and the CDC, professional medical associations, public health organizations, the insurance industry, and others have all recently issued new guidelines and policies on the proper administration of opioids and the treatment of individuals with opioid addiction.
Despite, or perhaps because of this attention, the President’s Commission report was eagerly anticipated. When released in final form on November 1, 2017, the report was widely praised for its comprehensive attention to the many factors that have combined to create the perfect storm that is today’s opioid crisis. There were reservations, however, because the Commission did not recommend any specific funding amounts to implement its recommendations. Moreover, President Trump’s decision to declare the opioid epidemic a public health crisis rather than a national health emergency also meant that no new funding has yet been allocated. The President’s Commission did advocate, however, that an unspecified amount of increased resources be put towards implementing its 56 recommendations.
We will highlight some critique and opinions about these recommendations specifically for healthcare providers and prescribers, organizations, funders and insurers, government and law enforcement agencies, and patients.
Providers and prescribers will see that the recommendations are largely extensions of current practice and therefore are relatively unsurprising. Adopting policies to ensure that patients give informed consent before receiving an opioid is consistent with current practice standards. Physicians should of course always discuss risks, benefits, and alternatives of any intervention they recommend for their patients. The concern here is that the informed consent procedure policies adopted be balanced. Opioids are proven effective analgesics for both acute and, in some instances, chronic pain and there are patients for whom they are clearly indicated. Informed consent procedures should, therefore, not be designed to frighten or discourage patients who need opioids.
Noteworthy, although not a departure from current policies and recommendations, is standardizing guidelines and extending them to specialists. Right now, there is a patchwork of opioid prescribing guidelines that have been created by multiple agencies. Many of them apply only to primary care providers. Currently, some states, like New York, have mandatory opioid continuing education requirements for relicensing and require that prescribers consult the state’s on-line Prescription Drug Monitoring Program (PDMP) before prescribing an opioid. These requirements would be extended to all states and a standardized national opioid prescribing curriculum would be created. It is unclear how effective continuing education programs are in improving opioid prescribing practices, so the benefits must be weighed against the burden it places upon physicians who must spend time taking more courses. Similarly, although there is some evidence that PDMP use reduces opioid abuse, it remains unknown whether this will have a significant effect in stemming opioid abuse.
Physician groups have complained that questions about how pain was handled that are included in patient satisfaction surveys contribute to unnecessary opioid prescribing. Fearing that negative reviews will be held against them; physicians report feeling pressured to prescribe opioids to patients with pain complaints to boost their ratings. The new recommendations mandate that CMS remove pain questions entirely from patient satisfaction surveys. This seems like a very positive step towards reducing inappropriate opioid prescribing.
Current practice is to refer patients reporting to the Emergency Department (ED) with signs and symptoms of opioid abuse or withdrawal to outpatient providers, but this can lead to poor follow-up and/or retention in treatment. Studies have shown that treatment, particularly with medications like buprenorphine/naloxone (Suboxone), can be started in the ED for such patients, who then are much more likely to enter outpatient treatment and remain drug-free for extended periods of time. Although some emergency physicians in the past have been reluctant to start medication assisted treatment (MAT) for patients in the ED, the recommendation to initiate substance abuse and addiction treatment in the emergency department could substantially improve outcomes for opioid addicted individuals.
Healthcare insurers will likely see an increase in their costs because of these recommendations. Nevertheless, these recommendations are all consistent with expert opinion. Right now, insurers incentivize physicians to prescribe opioids rather than alternative analgesic interventions, a policy that is widely criticized. For example, it is less expensive for patients to fill a prescription for a generic opioid than it is to have acupuncture or cognitive-behavioral therapy, even though both of the latter are among the non-opioid interventions that can be effective and far less risky in treating pain than opioids. The President’s Commission appropriately recommends modification of rate-setting policies that discourage use of non-opioid treatments for pain. It also calls for insurers to remove barriers for all forms of substance use disorder (SUD) treatment, including MAT. There is widespread agreement among experts that MAT is a safe and effective treatment for SUD and that its use should be expanded significantly. Finally, the recommendations call for stricter enforcement and stiffer penalties for insurers that violate mental health and parity laws. Although this last recommendation will certainly win the approval of advocates, enforcing the parity laws currently in effect has proven to be extremely difficult.
The creation of drug courts in all 93 federal judicial districts has already won widespread approval. Individuals with an SUD who violate parole would be referred to a drug court rather than sent to prison. Sending SUD patients to prison is generally seen as counterproductive and diversion to treatment via drug courts reduces recidivism.
Of course, all the above will have tremendous impact on patients who have pain-related illnesses or who are struggling with problematic opioid use. One recommendation that has not been met with much approbation, however, is for a media campaign to address “the hazards of substance use, the danger of opioids, and the stigma.” Some have criticized this recommendation as being too vague. It is unclear that such a campaign would significantly alter public perception or behavior. It also runs the risk of discouraging people who are legitimately taking opioids for severe pain, such as cancer patients, from adhering to prescribed regimens. The hope is that if a media campaign is pursued, that it is carried out in an evidence-based manner that incorporates what is known from social science about effective methods for changing attitudes and behavior.
Conclusions:
The most immediate concern about the President’s Commission report is that no funding is yet attached to its recommendations. One member of the Commission, former Rhode Island congressman Patrick Kennedy, was quoted as estimating that Congress needs to appropriate at least $10 billion immediately for the Commission’s recommendations to be carried out.
Another concern is whether the President’s Commission report takes into consideration the need to balance medically-indicated opioid prescribing with abuse/overdose prevention. Opioids are effective analgesics that can be a highly appropriate treatment for severe pain in both acute and chronic situations. But there is no question that they are currently prescribed in many situations for which other, less perilous, alternatives are effective and available. Nor is there any disagreement that opioid misuse and abuse have reached epidemic proportions and that the quantity of opioids prescribed must be reduced. However, patients who need to take opioids must not be stigmatized, nor must physicians be frightened to prescribe them when its necessary.
Overall, barring the concerns about funding and some skepticism around the proposed media campaign, the recommendations have been met with optimism. They provide a multi-prong approach to an enormous problem and include many evidence-based recommendations.
For further information on this topic, a free webinar will be taking place on Tuesday, December 12 at 2pm EST. Titled, Opioid Commission Final Report: Recommendations and Effects on Payers, Insurers, and Providers, the webinar will be led by Susan Kansagra, MD, MBA – Section Chief - North Carolina Division of Public Health, Chronic Disease and Injury Section, North Carolina Department of Health and Human Services, and Jason E. Vogler, Ph.D., CS SBB, Senior Director - Division of Mental Health, Developmental Disabilities and Substance Abuse Services
North Carolina Department of Health and Human Services. Registration for the webinar is available here.
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